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Pediatrics: Developmental and Behavioral > MEDICAL TOPICS
Child Abuse & Neglect: Failure to Thrive
Article Last Updated: Apr 2, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Andrew P Sirotnak, MD, Department Head, Child Abuse and Neglect, Director, Kempe Child Protection Team
Andrew P Sirotnak is a member of the following medical societies: American Academy of Pediatrics
Coauthor(s):
Antonia Chiesa, MD, Senior Instructor of Pediatrics, University of Colorado at Denver Health Sciences Center
Editors: Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences; Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
failure to thrive, child abuse, child neglect, FTT, organic failure to thrive, nonorganic failure to thrive, pediatric growth failure, maternal or parental deprivation syndrome, nutrition, neglect, malnutrition, cigarette use, sepsis, jaundice, feeding intolerance, phenylketonuria, inborn errors of metabolism, diarrhea, dysphagia, substance abuse, cachexia, marasmus, Down syndrome, achondroplasia, Turner syndrome, ptosis, sunset sign, palpebral fissures, toxoplasmosis, rubella, cytomegalovirus infection, herpes simplex, TORCH, cataracts, palate deformity, submucous cleft, glossitis, thrush, organomegaly
Background
Although the discussion of pediatric growth failure can be traced back over a century in the medical literature, the term failure to thrive (FTT) has only been used in the past several decades. The previously used dichotomy of nonorganic (environmentally related) and organic growth failure is the result of either inadequate calorie absorption, excessive calorie expenditure or inadequate intake of calories.
The objective parameter is usually the deceleration of growth height and weight. If FTT is severe, the parameter is poor brain growth as evidenced by head circumference. The diagnosis is based on growth parameters that (1) fall over 2 or more percentiles, (2) are persistently below the third or fifth percentiles, or (3) are less than the 80th percentile of median weight for height measurement. Growth failure is now generally accepted to be overly simplistic and obsolete.
A good working definition of growth failure related to aberrant caregiving is the failure to maintain an established pattern of growth and development that responds to the provision of adequate nutritional and emotional needs of the patient. Most cases of FTT are not related to neglectful caregiving, although it may be a sign of maltreatment and should be considered during an evaluation for growth failure.1 A joint clinical report by the American Academy of Pediatrics Committee on Child Abuse and Neglect and the American Academy of Pediatrics Committee on Nutrition outlines 3 indicators of neglect: “Intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child’s well-being; and family that is resistant to recommended interventions despite a multidisciplinary team approach.”2
Frequency
United States
Incidence of true growth failure of children in the United States is not accurately known. However, nearly 20% of children younger than 4 years live in poverty, and the inability to obtain adequate food is directly related to such conditions.
International
International problems of poverty and hunger occur in many nations. The death rate from malnutrition and infection for these countries can be high.
Mortality/Morbidity
The morbidity of malnutrition as a separate clinical entity is discussed in Malnutrition. Malnutrition that accompanies FTT can lead to significant developmental delays in children. The first 2 years of a child’s life are a sensitive period of rapid brain growth when neurodevelopmental outcomes can be influenced. Motor, fine motor, speech, language, and cognitive delays have been documented. The resultant poor cognitive ability can lead to emotional and behavioral problems as well. Children die each year in the United States from malnutrition; some severe cases are directly related to intentional child neglect.
Race
No racial predilection is noted because growth failure related to aberrant caregiving can affect people of all races.
Sex
No sex predilection is important to note.
Age
Growth failure for this discussion is described in children from infancy through the toddler period.
History
The history for evaluating pediatric growth failure and malnutrition is addressed in detail elsewhere. This discussion addresses the infant with failure to thrive (FTT) primarily related to nonmedical (eg, environmental, psychosocial) causes.
- Maternal medical history should include the following:
- Maternal age
- Gravidity
- Parity
- Abortions
- Pregnancy health history, including a detailed history of weight gain, prenatal care, substance or cigarette use, nutrition and unusual nutritional practices, general complications, bleeding, infections, fevers, and toxemia
- Labor and delivery and complications, if any
- Neonatal medical history should include the following:
- Gestational age determined at birth
- Intrauterine growth rate (IUGR)
- Apgar scores
- Birth weight, length, and head circumference with percentiles
- Neonatal course and complications, including sepsis, jaundice, feeding intolerance, or feeding difficulties
- Detailed medical history of newborn period
- Completed review of newborn screens (eg, phenylketonuria [PKU], other inborn errors of metabolism)
- The infant's or child's history should include the following:
- Medical-based history to exclude medical causes
- Feeding and nutritional history
- Growth and developmental progress
- Postnatal medical history should include the following:
- Immunizations
- Allergies
- Medications
- Food intolerance
- Formula intolerance
- Weight loss
- Diarrhea
- Vomiting
- Dysphagia
- Snoring
- Sleep apnea
- Recurrent respiratory or other bacterial and viral infections
- Signs of immune deficiency
- Malabsorption symptoms and signs
- CNS abnormalities
- Developmental delay or delayed or regressed milestones
- A detailed history of food intake from infancy through the current period is vital, and feeding history should include the following:
- Age-adjusted and age-dependent dietary details - Milk, formula, solids, vitamins, other supplements, food allergy or intolerance
- Feeding behaviors - Sucking, chewing, and swallowing difficulty; limited food preference or negative responses to food and feeding; frequency and timing of meals
- Caregivers' knowledge - Nutrition and feeding, dietary beliefs, religious and cultural beliefs about food, any unusual diets that might be inappropriate for a child
- Basic food and nutritional needs - Anything that prevents the family from (or assists the family with) getting food (eg, finances, transportation, subsidized programs); appropriate and safe preparation of food by the caregiver (eg, clean water, housing or shelter, cooking facility, refrigeration, cooking knowledge)
- Issues of nutritional ignorance (inadequate amounts or types of food, unusual dietary beliefs)
- Review of all developmental milestones for infancy and childhood, looking for either failure to attain or regression from the norm at specific ages
- The details of the psychosocial history are vital and should include the following:
- Finances, poverty risk factors (In 2004, food insecurity was identified in 42% of low-income houses with children younger than 6 y.2)
- Environment (eg, 1 bedroom apartment, 4 adults, 4 children)
- Family structure
- Caregiver identity and responsibility
- Daycare use
- Beliefs about child rearing
- History of abuse or neglect
- Prior child with growth problems
- Family substance abuse or addiction
- Violence or chaotic family structure
- Risks for or signs of maternal postpartum depression
- Educational level of parent or caregiver
- Employment with caregiver arrangements
- Food subsidy (eg, food stamps, Women, Infants, and Children [WIC] Program)
- Transportation problems
- Welfare or other aid programs
- Health insurance
- Family or cultural concepts on feeding and specific foods
Physical
The physical examination must be detailed and carefully performed to detect any disease or syndrome that might affect growth and development. The examination most often reveals a rather small and undernourished infant with normal vital signs and with most developmental milestones either intact or mildly delayed. Hospitalization is only needed for the rare infant with signs of severe malnutrition as evidenced by cachexia or marasmus.
Plotting growth parameters on the appropriate growth chart is essential. Multiple data points are helpful to evaluate trends in growth. Weight should be measured with the child unclothed. Length (not height), head circumference, weight for height and body mass index should also be plotted. Some conditions, such as Down syndrome, achondroplasia, and Turner syndrome, require specific growth charts.
- Vital signs - Temperature, blood pressure (in 4 extremities in an infant or one arm and one leg in young child), pulse, respiration
- General - Appearance, activity, affect
- Skin and hair - Poor hair texture and amount, nails, alopecia, hygiene, rashes, birth marks, trauma (eg, bruises, burns, or scars as signs of physical abuse)
- Head - Size, frontal bossing, fontanel size and patency, dysmorphia
- Eyes - Dysmorphia, ptosis, sunset sign, palpebral fissures, pallor, trauma, optic discs, fundi for evidence of chorioretinitis (toxoplasmosis, other infections, rubella, cytomegalovirus infection, and herpes simplex [TORCH]), cataracts (TORCH or inborn errors of metabolism)
- External ears - Size, shape, position, infection
- Middle ears - Infection, acute or chronic
- Mouth and pharynx - Palate deformity, submucous cleft, tongue, teeth, caries, glossitis, mucous membrane hydration or lesions, thrush, bleeding, unusual odors to the breath
- Neck - Shape, web, masses, nodes, thyroid abnormalities
- Chest - Breath sound, cardiac examination for murmurs or cardiomegaly or arrhythmias
- Abdomen - Protuberance, organomegaly, masses, bowel sounds, normal umbilicus healing in infant
- Genitalia - Normal for age, malformations, ambiguous in quality, hygiene, trauma
- Extremities - Edema; digit malformations; examination of the nails, joints, spine, and back
- Neurologic function - Cranial nerves, reflexes (increased or decreased), tone, infant reflexes present or extinguished at appropriate age, gait, suck/swallow coordination
- Muscles - Muscle development and quality and texture of muscle mass
- Adversive behaviors - Gaze avoidance, arching, hypertonicity, refusal to attach or respond appropriately, unusual body movements
Causes
See History.
Child Abuse & Neglect: Physical Abuse
Cystic Fibrosis
Gastroesophageal Reflux
Growth Failure
Growth Hormone Deficiency
Human Immunodeficiency Virus Infection
Other Problems to be Considered
Munchausen syndrome by proxy
Inborn error of metabolism and metabolic disease
Other endocrine disorder (thyroid disease, diabetes mellitus)
Genetic disorder
Malabsorption
Formula intolerance or allergy
Renal tubular acidosis
Congenital heart defect Infants who are premature and who have had complications in the newborn period are at risk for growth failure. Premature infants who have intensive care needs at home are at greater risk for neglect or abuse.
Lab Studies
The history and physical examination should guide any laboratory or ancillary testing. Most infants and children with growth failure related to environmental factors need very limited laboratory screenings. In the young infant or child, a few prudent baseline tests maybe indicated. - Initial and follow-up newborn screening tests
- CBC count - WBC and RBC indices for possible indication of occult infection, microcytic or hemolytic anemias, or immune deficiency
- Urinalysis and culture - Hydration status (if warranted) with specific gravity, evidence of infection, renal tubular acidosis
- Renal function - Serum electrolytes, BUN, and creatinine levels
- Liver function - Liver function tests considered in children with signs of protein wasting or organomegaly
- Additional testing as needed or indicated
- Human immunodeficiency virus (HIV) testing if risk factors are noted or if history and examination are at all suggestive
- Sweat test for cystic fibrosis
- Zinc level reported to be low in malnourished infants and children
- Metabolic and endocrinology screening (only as needed)
- Tuberculosis testing
- Stool studies
Imaging Studies
- Imaging studies are not routinely needed.
- Perform skeletal survey for occult trauma if physical abuse is suspected or signs are present upon examination.
- Head CT scanning or MRI studies are indicated if examination reveals microcephaly, macrocephaly, or congenital malformation or if abusive head trauma is a concern.
- Perform bone age studies of wrists in children who have constitutionally short stature or are extremely malnourished; in patients in whom bone density or ricks is a concern, perform knee studies, wrist studies, or both.
Other Tests
- Most other tests are not indicated unless a specific disease process is suspected that warrants investigation.
Procedures
- Most other procedures, invasive or not, are not indicated unless a specific disease process is suspected that warrants investigation.
Medical Care
- Observation of feeding is very important. Pay careful attention to the following:
- Maternal (caregiver) attachment during the feeding process;3 evaluation of signs of maternal attachment (eye contact, vocalizations, interpretation of cues)
- Evaluation of the child-parent dyad (eg, conflict over eating related to poor limit setting, lack of discipline, or meal time disruption)
- The perception of parents and/or caregivers regarding the problem
- Feeding techniques (forced feeding)
- A 72-hour diet diary that includes the following can be helpful:
- Details relative to growth from breastfeeding or bottle-feeding
- Formula preparation and amounts provided
- Time and amount of feedings (eg, 5 oz of Enfamil; one-half jar of strained peaches)
- Behaviors of infant or child during feeding or nursing
- Nutritional treatment is based on aggressive feeding to prevent cognitive loss. Most children require 100-120 kcal/kg/day, but this may be increased to achieve catch-up weight gain that is greater than normal. Other dietary instructions should include the following:
- Eliminate empty calories from items such as soda or other high sugar drinks.
- Schedule regular meals and snacks (usually 3 meals and 2 snacks per day). No grazing between meals.
- Offer solids before liquids.
- Consider fortifying calories with extra oils and carbohydrates.
- Increase protein.
- Consider vitamin and/or mineral supplements, especially zinc and iron.
- Provide support for the caregiver and offer suggestions for improving the feeding environment, such as the following:
- Avoid blaming the caregiver.
- Provide respite for the caregiver.
- Avoid distractions, such as television, at meal time.
- Offer a role model for the caregivers.
- Psychosocial evaluation must be detailed and must provide an in-depth look at the functioning of the family and the child in the context of the family. Many impoverished and/or uneducated parents have children with growth failure; however, many have children with normal growth. The background of the parents and their attitudes and beliefs about child rearing may affect how their children are fed and how they grow. An appropriate beginning for this inquiry is to ask family members about their perception of the child's growth failure and medical condition. Inquire about the caregivers' level of concern and note whether it is discordant with the physician's level of concern. Often, a disturbance in bonding may be obvious, but signs of problems with attachment can also be subtle. Note whether caregivers are changed or substituted frequently at feeding times. Current and past social history of the family, at a minimum, should address the following:
- Finances and resources, living and childcare arrangements
- Abuse and neglect risk factors, including any physical or sexual abuse
- Domestic or interpersonal violence
- Substance abuse or addiction
- Mental health disorder, particularly depression and postpartum depression
- Eating disorder
Surgical Care
Surgical care is most often not needed unless an underlying condition, such as cleft palate, must be repaired. Gastrostomy feeding tube placement may be needed in severe cases of malnutrition, especially in children with neurodevelopmental delay.
Consultations
An interdisciplinary approach is vital in the assessment and care of infants and children with failure to thrive (FTT) and growth failure, especially when the cause is predominantly psychosocial. Even in cases where organic or medical causes are predominant, a coordinated team approach helps the family understand the diagnosis and care plan.
- Consult a nutritionist early for evaluation of caloric needs, for anthropometric measurements, and for assistance with a dietary plan of care.
- Involve developmental specialists early on to provide baseline assessment, monitor growth, and monitor for any delays and improvements over time.
- Consulting a physical or occupational therapist may be necessary for patients with motor delays and weakness. A pediatric therapist who can assist with treatment plans can assess oromotor feeding skills. Most pediatric care facilities have oromotor skill therapists who provide this evaluation.
- Mental health professionals, including social workers, behavioral-developmental pediatricians, psychologists, and psychiatrists, are crucial in the evaluation of the family and child. They are also necessary to provide support for the caregiver and child.
- Parent education secondary to parenting skill assessment can offer valuable help and may be provided as well.
- In-home assessment is important to evaluate the environment, resources, and feeding interactions in the usual setting.
- An infant with growth failure from a dysfunctional care setting or family environment may thrive when placed in a more functional caring home. Reporting to county social services (child protection services) may be indicated with the following:
- If risk, suspicion, or documented abuse or neglect is observed
- If situations or factors are present that cannot be addressed by the care team alone (eg, homelessness, substance abuse, violence, family uncooperative with the care plan) because the infant or child can be considered a victim of medical care neglect
- If the family needs monitoring and support to assure compliance
Diet
Diet is outlined above. Diet must be individualized according to the age and nutritional status of the child or infant. Simply increasing the patient's energy intake may not cause growth to occur if the underlying comorbid psychosocial pathology is not addressed as well.
Activity
Activity may be adjusted with physical therapy if needed.
No medication is routinely needed unless an underlying condition is a factor (eg, infection, gastroesophageal reflux, cardiac or lung disease).
Further Inpatient Care
- Failure to thrive (FTT) is considered a medical emergency in infants or toddlers who weigh less than 70% of the predicted weight for length.
- Watch for refeeding syndrome.
- Most infants and children younger than 1-2 years can be treated with a coordinated outpatient care plan. Far fewer patients are hospitalized as inpatients today because of the development of appropriate and focus-specific outpatient care clinics and poor reimbursement for inpatient care.
- Patients with severe malnourishment who have had either no previous workup or for whom outpatient care has failed may require hospitalization.
- Hospitalization may be required in cases of suspected abuse or neglect, as well as for patients who are perceived to be in an unsafe environment. Foster care placement may be a subsequent requirement.
- Nasogastric and gastrostomy tubes should be reserved for the most severe cases.
Further Outpatient Care
- Carefully monitor growth parameters and overall development. Continue weekly weight checks using the same clinic scale until sustained growth is documented for months.
- Provide home visitation services either through public health resources or through a hospital/clinic program as the situation warrants.
- Monitor support services aggressively in conjunction with the involved agencies, in particular, local child protection services.
- Use the care team regularly and include the family and all involved specialists at team meetings.
- Closely document the child’s clinical course.
Deterrence/Prevention
Prevention of growth failure related to parental neglect and family and/or social dysfunction can be viewed on primary, secondary, and tertiary levels.
- Primary prevention involves careful assessment and monitoring of all families in primary care practice for any risk factors as reviewed above.
- Secondary prevention involves monitoring and intervention when these risk factors or situations are identified in a family or child. Consider early intervention as a mode of prevention in cases in which the physician is preventing the potential morbidity of growth failure.
- Tertiary prevention involves cases that have been identified and where intervention has begun to address the growth failure. Prevent further growth failure, with the resultant developmental disability and poor outcome morbidity, by creating and implementing a care plan that involves detailed review (see Treatment).
Prognosis
- Early diagnosis is crucial.
- Growth, development and behavior can be affected.
- Prognosis should be guarded for infants and children with severe malnutrition. If abuse and neglect are comorbid in a case of FTT, the degree of risk and risk factors for poor outcome increase in complexity and potential for poor outcome increases.
- With early intervention and treatment, the overall outcome can be promising for infants and children who respond to the nutritional and environmental interventions needed.
- Nutritional and growth improvement alone does not mean that all problems are resolved.
Patient Education
- As noted above, patient education is one of the most crucial elements of the care plan for these patients. It involves education dealing with nutrition, feeding, and normal child behavior and development.
- Also shared with caregivers are the interventions and therapy needed for the patient and those needed to address the family or caregiver pathology or dysfunction.
- Consider such education a long-term requirement throughout the early years of the child's growth and, in some situations, for the entire childhood.
Medical/Legal Pitfalls
- The most significant pitfall occurs when the focus is exclusively on a medical differential diagnosis and the complex psychosocial factors that can affect pediatric growth are disregarded.
- The clinician must consider the recognition of failure to thrive (FTT) or growth failure as a possible presentation of child neglect that requires intervention when constructing a differential diagnosis. Mandated reporting laws for child abuse and neglect are in effect in all states but may differ in the requirement or definition of neglect and may not specifically state FTT as a reportable form of neglect.
| Media file 1:
This 6-month-old infant was admitted with marasmus. The infant was born to a mother who did not bond effectively because of postpartum depression. He has evidence of severe wasting and neglectful care as also evidenced by the diaper excoriation. Weight gain was achieved by placement in foster home. |
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Media type: Photo
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Child Abuse & Neglect: Failure to Thrive excerpt Article Last Updated: Apr 2, 2008
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